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APPLICATION FOR DEPARTMENT OF THE ARMY PERMIT(33 CFR 325) OMB APPROVAL NO.(RENEWAL PENDING)
<br /> The public burden for this collection of information is estimated to average 10 hours per response,although the majority of applications should require 5 hours or less.
<br /> This includes the time for reviewing instructions,searching existing data sources,gathering and maintaining the data needed,and completing and reviewing the
<br /> collection of information.Send comments regarding this burden estimate or any other aspect of this collection of information,including suggestions for reducing this
<br /> burden,to Department of Defense,Washington Headquarters Service Directorate of Information Operations and Reports,1215 Jefferson Davis Highway,Suite 1204,
<br /> Arlington,VA 22202 4302;and to the Office of Management and Budget,Paperwork Reduction Project(0710-0003),Washington,DC 20503.Respondents should be
<br /> aware that notwithstanding any other provision of law,no person shall be subject to any penalty for failing to comply with a collection of information if it does not
<br /> display a currently valid OMB control number.Please DO NOT RETURN your form to either of these addresses.Completed applications must be submitted to the
<br /> District engineer having jurisdiction over the location of the proposed activity.
<br /> PRIVACY ACT STATEMENT:Authorities:Rivers and Harbors Act,Section 10,33 USC 403;Clean Water Act,Section 404,33 USC 1344;Marine Protection,
<br /> Research and Sanctuaries Act,33 USC 1413,Section 103.Principal purpose:Information provided on this form will be used in evaluating the application for a permit.
<br /> Routine uses:This information may be shared with the Department of Justice and other Federal,state and local government agencies.Submission of requested
<br /> information is voluntary;however,if information is not provided,the permit application cannot be evaluated nor can a permit be issued.
<br /> ITEMS 1 THROUGH 4 TO BE FILLED IN BY THE CORPS.
<br /> 1.APPLICATION NO. 2.FIELD OFFICE CODE 3.DATE RECEIVED 4.DATE APPLICATION COMPLETED
<br /> YOU ifl0 NOT NEED TO COMPLETE THE SHADED AREAS.
<br /> All applicants need to complete non-shaded items 5 and 26.If an agent is to be used,also complete items 8 and 11. 41111111
<br /> This optional Federal form is valid for use only when included as a part of this entire state application packet.
<br /> 5.APP ICANT'S NAME // 8.AUTHORIZED AGENT'S NAME AND TITLE(an agent is not required)
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<br /> 11. STATEMENT OF AUTHORIZATION(if applicable;complete only if authorizing an agent)
<br /> I hereby authorize to act in my behalf as my agent in the processing of this application and to furnish,
<br /> upon request,supplemental information in support of this permit application.
<br /> APPLICANT'S SIGNATURE: DATE:
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<br /> 26.Application is hereby made for a permit or permits to authorize the work described in this application.I certify •that the information in this
<br /> application is complete and accurate.I further certify that I possess the authority to undertake the work described herein or am acting as the duly
<br /> authorized agent of the applicant.
<br /> " '4 5 2-i—"/
<br /> Signature of applicant Date Signature of agent(if any) Date
<br /> The application must be signed by the person who desires to undertake the proposed activity(applicant),or it may besigned by a duly authorized agent if the statement
<br /> in Block 1 i has been filled out and signed.18 U.S.C.Section 1001 provides that:Whoever,in any manner within the jurisdiction of any department or agency of the
<br /> United States knowingly and willfully falsifies,conceals,or covers up with any trick,scheme or disguises a material fact or makes any false,fictitious or fraudulent
<br /> statements or representations or makes or uses any false writing or document knowing same to contain any false,fictitious or fraudulent statements or entry,shall be
<br /> fined not more than$10,
<br /> 000 or imprisoned not more than five years or both.
<br /> ENG FORM 4345,Jul 97 EDITION OF FEB 94 IS OBSOLETE. (Proponent:CECW-OR)
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